Answering Your Questions About Erectile Dysfunction with Raevti Bole, MD

Podcast Transcript

John Horton:

Hey there, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

When it comes to erectile dysfunction, or ED, guys have questions they're not always willing to ask, but they do have questions. That's why we're doing a special Q&A version of the podcast today with urologist Raevti Bole, who specializes in male reproductive health. Dr. Bole is going to answer some of the most common things fellas want to know about erectile dysfunction but seem a little hesitant or even embarrassed to ask. Along the way, we'll address a few myths and misconceptions about ED, too. So, with that, let's find out what could be happening downstairs when things aren't working quite like guys want.

Dr. Bole, thanks for coming back on the podcast to talk about, well, I guess things guys don't often talk about.

Dr. Raevti Bole:

Thanks for having me back.

John Horton:

So, you're with us today to talk about erectile dysfunction, or ED, which, as we know, can be a very sensitive subject for men. How do you go about starting these discussions and making guys feel comfortable talking about it?

Dr. Raevti Bole:

Yeah, that's a really good question. For me personally, I like to start just by asking an open-ended question, like tell me what's been going on in your own words. And I say that because I really want guys to feel like they can use whatever language comes naturally to them. So, a lot of guys are worried that they won't know what medical terms to use or that they're going to be impolite because, of course, you don't necessarily talk about these kinds of topics in society, but [inaudible 00:01:46]-

John Horton:

It doesn't come up with the fellas a lot when you're out with them.

Dr. Raevti Bole:

No. And so people are uncomfortable or they don't exactly know what to say. And I often tell people, there's really no correct way to talk about this. Tell me whatever you're comfortable saying, and then we go from there. If you tell me something out of order or if you skip a fact that it's actually important for me to know, that's OK. I'll remember and then I'll ask you while we're talking. So, I really try to emphasize that the important thing is that you made the appointment and that you came to see me, whether it's in person or virtual. So, congratulations on being here.

John Horton:

Do you find out, or I guess, do studies even show that a lot of guys just don't come in and just kind of live with it and maybe struggle with it?

Dr. Raevti Bole:

Yes. So, there's a ton of research and also anecdotally telling us that men are not very good at going to the doctor and that they will do anything but go to the doctor. And they'll really put it off until they really can't ignore the problem anymore. And so when someone comes in and talks about something so personal, I think that's actually a sign of courage. I think it's a big sign that something actually is very wrong because you know that most guys wouldn't have come in if it were something they could have ignored.

John Horton:

Well, for those who don't want to come in or are hesitant to, that's why you're here today. So, we're going to try to tackle some of the more common questions that come up about erectile dysfunction to help get the info out there for the people who need it, and maybe kind of bolster their confidence and they will come in and see what can be done.

So, let's kind of start with a basic question: Is ED just a normal or even unavoidable part of getting older?

Dr. Raevti Bole:

That's a good question. I would say just because someone is older does not mean that they need to have ED if they're otherwise healthy. But what we do know is that it's also more common to have some of these chronic conditions as you get older. Even if you are on treatment for the conditions, it's more common to have things like high blood pressure or high cholesterol or diabetes as a 70- or 80-year-old rather than a 20- or 30- or 40-year-old with those conditions. So, I think it's more of a factor of those conditions causing ED than just pure age alone. Because I do see plenty of guys who were in their 70s, 80s, they're pretty fit, they're healthy, they don't have high cholesterol, they don't have high blood pressure, they're not diabetic and their erections are very satisfactory to them.

John Horton:

Wow. One more perk of staying in shape, I guess.

Dr. Raevti Bole:

Absolutely. Yeah.

John Horton:

There's all these advantages.

Dr. Raevti Bole:

Huge advantages.

John Horton:

Another thing you hear a lot is that erectile dysfunction can be a sign of another health issue. What can it be telling us?

Dr. Raevti Bole:

So, the data we have, and there's a lot building up now, tells us that, on average, men will notice a difference in the quality of their erections before they notice problems with their heart. So, almost three to five years before they might have some major cardiac event. And that is because the arteries in the penis are smaller than the ones in the heart, so they're going to get affected earlier on by things like cholesterol or high blood pressure. So, what that tells us is that you really want to focus on preventive health throughout your life so that that doesn't happen. If you're [inaudible 00:05:23]-

John Horton:

It sounds like it's the canary in the coal mine sort of thing.

Dr. Raevti Bole:

Yes, exactly. Canary in the coal mine. It's a great way to put it. And so if you are noticing that that's happening, if you're noticing the canary in the coal mine, get to the doctor. Make sure that you know your cholesterol, your blood pressure. Make sure that you have an accurate weight. Make sure your blood sugar levels. Look very critically at your diet and exercise to see if you need to change things. Because one thing you can do early on is prevent damage from progressing.

John Horton:

And I'm guessing with this, it's not that just one morning you wake up and you no longer get an erection. This is one of those things, you might see a trend where just maybe it's not as erect or you have trouble every once in a while and you never did before. It sounds like those are kind of the warning signs you should pay attention to.

Dr. Raevti Bole:

Exactly. It's definitely a trend that you want to pick up on because I would say most guys can remember a time when their erection wasn't the greatest, but maybe there was a reason — you were really stressed out, weren't really in the mood, that kind of thing. But then later on, it worked great. But if you're really noticing that there's a trend, like you said, multiple times where it's just not working, no matter that you are well rested, that you hadn't had a ton of drinks, you really were in the mood, and it's still not working, and that goes on and on, that would be worrisome. And that would definitely be a reason to mention to your doctor.

John Horton:

Yeah, something you got to be honest with yourself and really assess what's going on.

All right, now another thing. Guys are pretty familiar with a phenomenon known as nocturnal penile tumescence. I think that's the — hopefully I said that right — but I think we know it better as “morning wood.” If that's not happening, is that a potential sign that maybe you have some ED issues creeping in?

Dr. Raevti Bole:

Yeah, absolutely. So, nighttime erections are linked to sexual health. They're very closely related to things like good hormone production. So, if they really aren't happening, that could be a sign that there's something else going on. An early sign of ED or something dysregulated with hormones. Sometimes, it's difficult to know whether you are still having them at night unless you're testing for it. There's some cool wearable technologies coming out that can track for this. There isn't a lot of data on it yet, but I imagine there will be in the future. Just kind of funny. But the old school method that used to be done is something called the stamp test. So, you would wrap a strip of stamps around the penis at night, and if it was broken in the morning, then you would say, Oh, well, you probably had a nighttime erection. Don't do it anymore.

John Horton:

That is … wow, that's quite the research thing there. Yeah. Wow. OK. I got to recompose. That's going to take a while to absorb in here.

So, moving on with maybe potential causes of ED, could medications be a reason why all of a sudden you're having trouble down there?

Dr. Raevti Bole:

I think that's a complicated question because a lot of the time, you're taking medication to control one of the causes of ED. So, you take a medication for high blood pressure or for diabetes or for depression or for cholesterol. And then if you notice that maybe erections aren't as good afterward, you might think, Well, I want to stop taking it and then I'll be better. But the problem is that if you stop taking the medication, your underlying health issue isn't treated and you absolutely will get worse ED anyway.

So, I would say if you're noticing a change in the quality of erections and you really feel like it's related to a medication that you just started, talk to your doctor to see if there's an alternative dosing or an alternative formulation that you can try. Or maybe there is a treatment that we can put you on for ED that would work.

But I would say the worst thing to do is just to stop it and not treat that condition anymore.

John Horton:

And what you were just talking about was obviously kind of prescription drugs. What about over-the-counter stuff? I mean, if you're just hitting the ibuprofen a lot or aspirin, things like that — could that have an effect?

Dr. Raevti Bole:

I think it depends on the medication. So, if you're taking ibuprofen as needed for muscle aches and things like that, that I wouldn't link that to ED. If you're consistently taking ibuprofen, especially exceeding recommended amounts or taking it consistently longer than 10 days, that can cause other problems — stomach problems, ulcers, kidney problems — but they would have to go pretty deep to then subsequently cause ED.

John Horton:

Yeah. And it sounds like that might just be, you're taking these pills to mask symptoms of another condition, which could be contributing to it anyway.

Dr. Raevti Bole:

That's certainly possible.

John Horton:

Another thing you hear a lot is that ED is a psychological issue or it's just something in your head. Could that be what it is?

Dr. Raevti Bole:

In a sense, yes. I mean, so much of sex and the sexual connection is emotional and mental. You need to feel confident, you need to feel attractive, you need to feel attracted to your partner in order to have sex. You need to have a low stress level during, while you're being intimate. And so if you have a diagnosed condition, or symptoms maybe that haven't been diagnosed yet, like of depression or anxiety, that certainly could affect your confidence or your stress level during the time that you're having intimacy. And that's going to affect your ability to get a good, strong erection and maintain it. But even if you don't have a mental health condition like depression or anxiety, it's still really stressful for most guys to realize that their erections are unreliable. It's embarrassing, it hurts your confidence. And then also, a lot of people feel bad; they wonder, Am I satisfying my partner?

That's a lot of things to be thinking about during a time when you're really just wanting to focus on intimacy. So, a lot of guys have just plain old performance anxiety because it feels like there's so much at risk every time that they have sex. So, in that sense, absolutely, it is emotional and mental. And for that reason, a big part of what I talk to guys about is sure, maybe there are treatments that we can do for ED and absolutely we want to focus on preventive health, but I'm a big advocate of sex therapy as one of the components of a good treatment regimen because it is important to talk to a professional about some of the ways that your head can affect your erections.

John Horton:

Yeah, it sounds like it's probably better the less you're thinking about it, maybe the better your chances of everything working right might be.

Dr. Raevti Bole:

That's a good way to put it.

John Horton:

People always tie testosterone to how everything's working down there. Could erectile dysfunction be a sign of low testosterone?

Dr. Raevti Bole:

Testosterone levels certainly can contribute to ED if they're low, but I would say for the vast majority of people, it's not the primary cause. Now, low testosterone can certainly cause problems with arousal or what we call libido. And that's, of course, important in order to get an erection. But even if someone had low testosterone and we fixed it to where it was within normal range, they might still notice problems with erection hardness and need something additional to be done.

John Horton:

So, it sounds like if somebody is having problems with ED and they shouldn't just start taking testosterone on their own to try to address it, that's not going to help the situation?

Dr. Raevti Bole:

No. I mean, I would certainly advocate for checking it to see where it is, but no, I mean, even if it is low and you get on treatment for it, it may not, for most people, be the one thing that fixes the erections.

John Horton:

Now, for this next question, we all kind of know the classic term for this, but can alcohol contribute to ED?

Dr. Raevti Bole:

Yes. I would say in the moment, absolutely. It'll affect a lot of people's ability to get aroused, stay aroused, stay in the moment and maintain that erection. And then chronically, a lot of heavy alcohol use or frequent alcohol use is going to lead to hormonal changes and hormonal disruption that can then ultimately affect things like testosterone levels over time.

John Horton:

Yeah, it sounds like alcohol will maybe help get you in the mood, but it's not going to help the performance once you go to actually do it.

Dr. Raevti Bole:

Yeah, I think it depends on how much, too, because it's very easy to overdo it and then that's not helping anyone.

John Horton:

All right. Another thing where I've read online, people will tie too much caffeine, too many cups of coffee or Monster® drinks or whatever it is to ED issues. Is there a correlation there?

Dr. Raevti Bole:

I would say no. I'm also a big coffee drinker, and so I am always looking into the research about caffeine and what it does and what it doesn't do. And as far as men's issues with ED go, I would not tie caffeine to ED. There are actually some studies saying a little bit toward the opposite, that it might help. But I wouldn't say that the data is really strong.

John Horton:

Well, that's good to hear because I drink a lot of coffee, so I can relax a little on that one. What about tight underwear? That's another thing where people will kind of point the finger and say, Hey, maybe this is causing erectile dysfunction. Any truth to that?

Dr. Raevti Bole:

Yeah, that's a good one. And again, I would say no. Standard underwear, boxers, briefs, athletic underwear are not going to be causing ED. No.

John Horton:

Well, that's good to know. So, whatever's in that drawer, you can put on with confidence.

Dr. Raevti Bole:

Yes, confidence is key.

John Horton:

All right. What about logging a lot of miles on a bicycle? You're kind of sitting there, things are a little squished up. Is that going to undermine penis performance?

Dr. Raevti Bole:

Yeah, in terms of the research, I would say there's no clear connection to it. The theory … what we all think about is, well, if you have this constant pressure on your perineal area, that's where the base of the penis is. And so are you compressing the base of the penis, but you'd really have to be riding for hours a week on a very narrow seat — and have studied a lot of men doing this over a long period of time to determine this — I don't think there's strong data on it — but I would say from the physiology and from what we do know about bike riding and where all the structures are, if you're riding a bike and you have numbness or pain in that area, then I would definitely recommend using a wider seat, a padded seat that distributes the pressure. It's a little nicer. But I certainly wouldn't say, Oh, well, just don't ride bicycles. Riding bikes is good for your heart. It's good exercise, and if you're not having pain or numbness from it and you're feeling well otherwise, then I certainly wouldn't cut it out.

John Horton:

Yeah. It sounds like it's time to invest in some of those padded shorts or one of those cushy tushies that you can put over your seat.

Could erectile dysfunction be a sign of infertility?

Dr. Raevti Bole:

I wouldn't necessarily say so, but I do think that fertility problems and erectile problems share a lot of risk factors. So, some of the same things that will cause fertility problems, like heavy smoking or hormonal issues or diabetes, are going to be the same things that will affect erection health. So, by that token, I think it's worth investigating both. And they may have the same common cause.

John Horton:

All right. If you search online, there is no shortage of claims about certain foods being able to keep things working downstairs. So, is there a superfood to stop ED and get things going?

Dr. Raevti Bole:

Yeah, so when we talk about things that cause ED, a lot of what we talk about is cardiac. How do you maintain your heart health? And so I think from that standpoint, the ideal diet is going to be a heart-healthy diet. And more often now, we're thinking about that as something that's more … so plant-based. So, there are some studies showing that men who eat a lot more red meat, for example, are going to have a higher risk of cardiac disease and a higher risk, therefore, of ED. And then there are other studies showing that plant-based diets can potentially even reverse things like diabetes. So, if you're eating a lot of whole grains and legumes and things like that, if that has the ability to help your diabetes, again, that's going to be much better for preventing problems with your erections. So, those are the things that I would recommend for diet.

In terms of supplements, those are super popular to talk about. I would say it's difficult to study supplements in a research study and give people 100% evidence that something works or doesn't work. And that's because a lot of times, you see things that are sold as a proprietary formula or a blend of 50 different things and none of these supplements we actually know what's in them because they're not always tested by a third party. They're certainly not tested by the FDA. And so we don't always know what's in them. But there are a lot that are popular that are online and that people will tell you they work sort of anecdotally. And I would just say that for anyone interested in supplements, make sure that you do your research into what you're buying, make sure that it is third-party tested, make sure that you know what the sources are. You don't want to accidentally take something that's contaminated with pesticides or heavy metals or something else that you really don't want to be putting in your body.

John Horton:

Yeah, supplements can really be the wild, wild west when you're looking at, like you said, how they're overseen and there really aren't inspections. So, it sounds like you should probably be wary of anything that's making big promises on the label that it's going to do this specifically and try to find something that's a little more just for your health in general.

Dr. Raevti Bole:

Yes, exactly. And I would say, when you think about supplements, they're exactly that. They're meant to supplement a healthy diet. So, depending on what you eat, you may need one thing or you may need something else, and that might be different from your friend who's taking the same supplement that may not be the one that you need, depending on whether you're plant-based or eat more meat or you don't really eat your vegetables. I think for people who are interested, it's just important to do that deep dive before getting into something.

John Horton:

Now, we've kind of touched on this throughout, just how difficult erectile dysfunction can be for guys, and it can be embarrassing, and you don't quite know what to do when it's just not working when you want it to. What's the best way for someone experiencing that or having issues with it to talk to their partner about what they're experiencing?

Dr. Raevti Bole:

That's a good question. I think it really depends on who your partner is. I mean, is it someone that you just met? Is it someone that you've been dating for a short time? Is it your wife that you've been married to for a long time, who you know very well and she knows you very well? A lot of that is going to depend on your relationship and communication style. Are you someone who likes to use humor to bring up a serious topic or are you someone who would rather just keep it a little bit more serious? So, I think it takes some reflection on what your partner likes and how they like to communicate and how you like to communicate. But again, just showing up at the doctor, I think … I always congratulate guys for even attempting to have that conversation. Whatever way you try to approach it is the best way. The fact that you did it is what counts. And I think that if you're able to just sit down and authentically say, "Hey, it's not you, first of all, it's nothing to do with how I feel about you, but I'm having some trouble when we go to be intimate. My body isn't kind of working the way that I would expect it." I think if you are able to get that across in the best way that you know how the conversation then tends to flow a little bit more organically. And that's because most times, when you're talking to your partner, I mean that's someone who loves you, they're going to start asking follow-up questions and you're going to find yourself talking about it pretty quickly. So, I think just the first step is just making it clear that this is not reflective of your relationship together and just mentioning it.

John Horton:

That's great advice. It leads into maybe our last question here, and probably the most important one for a lot of guys, or what they want to know the most, and that is, is erectile dysfunction permanent?

Dr. Raevti Bole:

I think it depends on what the reason is. If it's more so something emotional or mental health or a medication that's causing it, that is easier to reverse. If there is physical damage that's happened to the nerves or the arteries, that can be more difficult. And there's research being done currently into more of restorative or regenerative technologies to try and reverse ED. And so I think that's really exciting. I think that's the future. But in many ways, we aren't quite there yet.

And so I think it's always a good idea to make changes to diet and lifestyle. If you find that making some of these changes actually reverse the issue, that's excellent. But I think the more important thing is that by making these changes, you can prevent the ED from getting worse. So, even if it feels like you're at a new baseline, at least you're not going to have it progress to where you're now really unhappy with the way that your sexual function is.

John Horton:

Yeah. How soon should you go and talk to a healthcare provider about ED? As we all know, we've seen the commercials, there are little pills available and things like that. It sounds like there is help there. It's just a matter of reaching out and asking for it.

Dr. Raevti Bole:

I would err on the side of mentioning it, especially if you're noticing a trend or it's happening not just once in a while, but more often than not, I would definitely err on the side of just mentioning it. The worst that'll happen is that your doctor checks all of your labs, does your vitals, tells you that you're healthy as a horse and don't need to worry. But if they find something that's worrisome or if you even try a pill for a little bit, that's temporary and then you realize, Hey, I really don't need this. That I think is a good risk-benefit for most people.

John Horton:

From what you just said, it sounds like if you go in and say, "Hey, listen, I'm having these issues," you get a whole battery of tests looking at a whole lot of body functions. So, I mean, it really kind of points to how erectile dysfunction could be a sign of something much, much larger.

Dr. Raevti Bole:

Yes, absolutely. And I think that's where we really go back to preventive health. All doctors will be the most focused on preventing you from getting sick. We're very good at treating you once you get sick, but the key here is prevention. So, if you have to see us just once a year or very little, that makes us happy.

John Horton:

And guys don't like going in, so that would be a very happy thing.

Dr. Raevti Bole:

It's a win-win.

John Horton:

So, Dr. Bole, if we just want to wrap things up, what's the one thing you want guys to take out of this podcast or to think about when it comes to erectile dysfunction?

Dr. Raevti Bole:

If I have one thing I would say, I would say that you were not alone. Problems with erections are a really common thing that guys worry about, and just take it out of your head that it's embarrassing. Take it out of your head that you're the only person this is happening to. It happens to honestly most people at some time in their life. And so don't be embarrassed. Just tell your doctor and use whatever language you need to convey what's going on. You're going to thank yourself.

John Horton:

Dr. Bole, I appreciate you coming in today and answering this kind of flurry of questions. I think we filled in blanks for a lot of guys, and I look forward to having you back on.

Dr. Raevti Bole:

Likewise. Thanks so much for having me.

John Horton:

Erectile dysfunction affects millions of men and is more common with age. If you're dealing with ED, talk to your healthcare provider to find solutions and ensure that it isn't a sign of a larger health issue.

If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Till next time, be well.

Speaker 3:

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